Thursday, 13 November 2014

Concentration of Neonatal Deaths and Role of Community Newborn Care Practices

Every year about 0.76 million neonatal
deaths (death within one month of the birth) occur in India, which accounts for
28 percent of such death in the world, the greatest for any country. About
two-thirds of infant deaths and half of under-five child deaths are during the
neonatal period. India’s Neonatal
Mortality Rate (NMR) stands at 29 deaths per 1000 live birth, and the states at
high risk include Madhya Pradesh (39), Odhisa (39), Uttar Pradesh (37),
Rajasthan (35) and Chhattisgarh (31).
Though the Neonatal Mortality Rate (NMR) has declined from 52 per 1000
live births in 1990 to 29 per 1000 live births in 2012 (SRS 2012) the declining
rate has been very slow as compared to many other developing countries and
emerging economic states.

A latest report ‘State of India’s
Newborn 2014’ released by Public Health Foundation of India (PHFI) reveals the
health disparities among newborns of various communities in India. According to
the report, health outcomes are shaped not just by biological factors but also
by the social, economic, and cultural environment. Social hierarchies and
inequitable distribution of resources produce significant inequalities in the health
and well being of people.

Considering the health inequality and
social inequality interface, the poorest and most disadvantaged have a higher
risk for diseases. This includes the urban and rural poor, female children,
specially-abled persons, and traditionally marginalized and excluded
communities like Scheduled Tribes (STs), Scheduled Castes (SCs), and ethnic and
religious minorities. They also have a higher probability of being excluded
from the health services. The PHFI report states that the newborn in these
populations are expected to be the most vulnerable to morbidity and mortality. It
is evident from the empirical data on Indian neonatal and child mortality that
mortality is high among children of these socially disadvantaged and
economically deprived communities. The report by Public Health Foundation of
India has also emphasized on identifying such communities. The report says that
doing this will help in identifying entry points for action and setting
priorities for long-term improvement in neonatal survival.

High Risk Communities

High Risk Communities

Status of Neonatal Deaths

Rural Population

In rural
areas, neonates are at two times more risk of dying, as compared to their
urban counterparts. Data has recorded Neonatal Mortality Rate as high as 33
deaths per 1000 live birth in rural India as compared to 16 for urban areas.

Source:
SRS

Women

As children get older, probability of
female mortality becomes higher than the males. Females have 36 percent
higher mortality than males in the post neonatal period, but a 61 percent
higher mortality than males at age 1-4 years.

Source:
NFHS-3

Dalits and Adivasis

Child born in
a SC family has 13 per cent higher risk of dying in the neonatal period and
18 percent higher risk of dying in the post-neonatal period, as compared to
others. Similarly, a child born in a ST family has 19 per cent higher risk of
dying in the neonatal period and 54 percent risk of dying in the post
neonatal period.

Source:
UNICEF

Educationally Disadvantage Section

Children born to a mother with at
least eight years of schooling have 32 percent lesser chance of dying in
neonatal period and 52 per cent lesser chances in the postnatal period, as
compared to illiterate mothers.

Source:
UNICEF

Newborn
Care Practices among High-risk Communities

Given the diversity of India, each
community and region have their own local newborn care practices. Most of these
practices are strong and legitimate, since they originate from local culture,
environment and religion. Some of them are also based on traditional medical
knowledge of the community regarding pregnancy and neonatal care. Traditional
Birth Attendants (TBAs) are the key stakeholders in practicing and delivering
traditional neonatal for the disadvantaged population in villages, slums,
tribal areas etc. Various studies on this issue have identified many practices
that are healthy for the survival and growth of the newborn. However, studies
also identify a number of hazardous practices that leads to many prevalent
causes of neonatal death such as sepsis, pneumonia, birth asphyxia, injuries,
tetanus and diarrhea. The lack of institutional care system and prevalence of
such harmful neonatal care practices are correlated to the higher concentration
of neonatal death in villages, slums and traditional communities. Some of these
practices are described here briefly to understand their impact.

Harmful Local
Neonatal Care Practices

Health Consequences

Home Delivery by Untrained Individual

More than one
third of deliveries in the rural areas are conducted outside health
institutions. One in every four deliveries is conducted by untrained
individual/person in the villages.

Common
practices in slums and rural areas identified by number of studies reveals
that most of the newborn were given a bath immediately after birth.

Bathing immediately after birth causes
hypothermia and may lead to death

Delay in Breastfeeding

According to
the latest SRS data, during 2012-13 as high as 3.72 million newborns in India
were not breastfed within one hour of the birth

The delay in breastfeeding and feeding
baby with any liquid and solid food other than mother’s milk before the age
of six month is a harmful practice for health and survival of the newborn.

Asphysia Care

To clean the
airway of secretion, the newborn needs to be held upside down and the back
slapped immediately after birth. Many studies found that there is a lack of
knowledge about asphyxia in communities across the country and also amongst
traditional birth attendants.

Asphyxia is one of the major causes of
the neonatal death in India. Common community practices such as holding the
baby upside down and patting or massaging it, blowing in the ears, sprinkling
and dipping it in water and making loud noises are harmful for the newborn

Postpartum Hygiene

Umbilical
cord care is a big issue in villages, tribal areas and in the slums.

Cord cutting and tying practices in
rural India is one among high risk factors for neonatal infections. The blade
is commonly used to cut off the umbilical cord in rural and geographically
difficult areas but following the steps of clean cord care remain a problem.
Most people lack knowledge about sterilization of the blade and after care.

Policy
Responses and Way Forward

The entire cycle of reproduction and
local cultural practices are intertwining. There are number of good neonatal
care practices but we have also witnessed a number of harmful practices that
fuel mortality of newborns. It shows us that the issue is not just medical but also
has social dimensions. Indian Maternal and Child health policies have always
addressed social aspect in various ways. In the last decade, National Rural
Health Mission promoted community level interventions through ASHAs. However,
TBAs remain the main source for delivering both good and bad community
practices. The Indian policies never took TBAs seriously to involve them in
health system other than providing them some skill trainings. There were no
serious efforts to exchange knowledge between TBAs and modern medical
professionals. Health system needs to accommodate TBAs and consider their
community influence, traditional knowledge and skills along with knowledge gap to
promote better neonatal care in the country.